According to Radio 4′s Today Programme, the number of hospital admissions across the UK of teenagers with eating disorders has nearly doubled in the last 3 years, according to NHS figures obtained by the BBC. 4,610 girls and 336 boys aged 15–19 develop a new eating disorder in the UK every year. While some blame instagram and others catwalk models, I’m inclined to sniff a little closer to home. No, literally closer — round the corner.

Your GP.

When we look for causes behind eating disorders, it is reasonable to question what qualifies a person as a sufferer in the first place. The answer, according to the medical profession, is your BMI. Standing for Body Mass Index, it can be calculated by taking weight in kilograms and dividing it by the square of your height in meters. It props up the majority of UK media stats on both obesity and anorexia, as well as official NHS reports on weight gain. While the NHS claim in the small print that it’s not accurate for all, your BMI can be the difference between an eat-more-greens-and-come-back-next-week slap on the wrist or hospitalisation. For teens that struggle with extreme weight gain and weight loss — it’s often their medical fate.

At 14, I was diagnosed with PCOS, a common but unpleasant condition that lets cysts on your ovaries affect your ability to lose or gain weight, among a plethora of other things. The male, middle-aged doctor simply stood me against a wall chart, popped me on the scales, did his merry maths and declared me ‘Very fat. Should lose weight. Very fat’.

After that I had an understandable fear of encountering BMI, but a fleeting urge to ‘get healthy’ a few weeks ago lead me to knuckle down and give the medical experts another chance. I opened my laptop to find out my current BMI according to the NHS website’s official calculator. Now, don’t get me wrong — I could do with a few more jogs and a few less pain au chocolats. I am acutely aware that I am a little unhealthy and would probably benefit from losing some weight.

This much though?

Sure, perhaps I was feeling a little cuddly — but according to the NHS website, it would not go amiss for me to lose FOUR STONE.

FOUR.

That’s almost a third of my total body weight. Let’s look at that again(apologies to all who know me in real life — semi-nudity is a necessary evil in this case)

Worried that I was suffering from obnoxious levels of self-love and was in fact obese, I sent the picture with my screenshot result to a few steely, blunt friends. Friends that wouldn’t Bulls**t me. It was the intellectual, more informed equivalent of a ‘does my bum look big in this’ request. The response was overwhelming and a more importantly, a ‘no’ — and soon I took to a wonderful forum of women to see if my slightly extreme results were the exception. They weren’t.

I asked girls my age, of all body types and variations, to submit pictures they were willing to share in this context, along side screenshots from the NHS website. As they were, in that moment. These were the results (please note: permission has been given for the use of these photos).

In the interests of ‘proper journalism’, I’ve included a range of results — obviously all conclusions are subjective, but you can see that some results are more plausible than others. Especially comparing those with similar results and completely different body sizes.

Luckily, the BMI scale is universally recognised as a guide, not a rule book. However, what won’t be made as apparent to you is that the BMI scale, or (as they refereed to it in 1835 when the research was carried out — yes, EIGHTEEN-THIRTY-FIVE) ‘Quetelet Index’, was only based on a sample of 100 ‘countrymen’. Not only that but it’s inventor, Adolphe Quetelet, warns within the very paper in which the BMI scale is conceivedthat this calculation is not intended for individual diagnosis — it is only proven to be useful when assessing huge populations, not on one person.

For me, as with many, a huge part of my tendency to binge-eat or avoid food is the dysmorphic way I see my body. Growing, shrinking, growing again — and labels like ‘overweight’ can be the most triggering of them all. Body-shaming scales that compare one bodily ecosystem with another, without proper support or full explanation, can devastate a teenage mind on the verge of illness — or in some cases like mine, actually create one. Joseph Matthews, Lecturer in Health at Worcester University, comments that ‘by classifying someone as underweight or obese, you’re not instigating lifestyle change, you’re attaching stigma and judgement. Change in health behaviours stem from empowerment. Unfortunately classifying an individual on the BMI scale can have the opposite effect.’

A misleading BMI diagnosis doesn’t just have an effect on those whose extreme result that contrasts with their less-than-extreme body size. Those who are suffering are often denied treatment when the NHS turns to them, brandishing their BMI of 17, and says ‘you’re not ill enough’.

As a mental illness, it is surprising that a mathematically physical diagnosis should determine a patient’s access to psychological treatment. Moreover, natural warning signs from the body can often be overlooked in favour of the nation’s favourite Golden Cow, BMI. As featured in The Guardian last Saturday, at 15 years old Nancy Tucker and her mother approached their local GP with concerns that Nancy was developing an eating disorder. Her BMI result wasn’t low enough to merit referral and she was turned away. Just three months later she was hospitalised and continues to fight the illness today.

Nancy Tucker

Now 21 and author of the The Time In Between: A Memoir of Hunger and Hope, Nancy is still speaking out against a 200-year-old measuring system gifted to us from an era that still believed hosing a woman down was the best way to treat her for hysteria. Speaking to me this morning she says, ‘In the grips of an eating disorder, you are terrorised by the conviction that weight is everything — that it determines your right to happiness, love, care, and even life itself. The current NHS practice of allotting eating disorder treatment according to BMI doesn’t just fail to undermine this twisted belief: it outright backs it up. When I was deeply, frighteningly enmeshed in bulimia, I went to an eating disorder psychiatrist for an assessment, clutching a letter from my private psychologist: ‘Nancy is bingeing and purging up to twenty times a day. Nancy is vomiting blood. Nancy has fainted eleven times over the past week. Nancy has tears to her oesophagus. Nancy reports feeling suicidal, and has clear plans for taking her own life.’ Mentally and physically, it was the sickest I have ever been (and my sickness standard is pretty high). The psychiatrist plonked me on the scales, tapped impatiently on her calculator, and scribbled away my right to treatment. Healthy BMI. I should have been hospitalised there and then. I was sent home on the bus, and put on a six-month waiting list for a course of four fifty-minute CBT sessions.’

The only warning on the NHS website that this is the case is a small line in a separate information window that reminds us that in extreme circumstances (like for rugby players) BMI won’t be entirely accurate — however it stresses that this fact ‘will not apply to most people’ and your BMI is on the whole a good measure. Above are pictures of ‘most people’. The NHS is there to serve ‘most people’. Where is the real science, the real rally for ‘most people’?

When you compare this to Instagram’s automatically programmed response (below) to any user searching the term ‘anorexic’ or ‘thinspo’— can we really claim that social media is the only problem?

In a social landscape where weknow these kind of issues are very near the surface, why make something so unreliable and a core part of public health examinations? BMI speculation (if you insist on them existing at all) should always be accompanied by a thorough and tailored medical examination. Any NHS employee should agree about that. Planting an arbitrary calculator on a ‘medical website’, accessible to any teenager or vulnerable adult without context, is surely the opposite of making sure that happens.

Why should we be expected to throw parties to rival Gatsby’s when underweight models are taken off the runway — yet sacrifice our sanity at the alter of ‘medical’ accuracy when it comes to our personal health? An informed medical website like NHS.co.uk is not the place to be posting speculative witchcraft of the highest (eating dis-)order.

Here are the instructions young girls will find accompanying this mathematical machine deigned to feed them with ‘answers’. Take a read yourself — but in my mind it’s far from good enough. If the BMI scale is ‘just a guide’, I’d like to ask ‘a guide to where?’. The grim reaper will surely see you to Hell quite efficiently, it doesn’t mean the destination is appealing. If a BMI ‘diagnosis’ should always be accompanied by medical advice, what business does its carcass-like calculating-system have hanging around on our National Health website? Who invited BMI and more importantly, now he’s crashed our party — who is going to tell him to leave?

Hi, sorry to be pedantic, but any chance of a trigger warning at the top of this article? For anyone with ED/body image issues a lot of these images are very triggering. Not a criticism of the article or the important issues it is aiming to raise.

Hi Suze
We don’t do trigger warnings – we thought the heading serves as enough of a flag. I consulted some people and they said that the mention of BMI as well as the sub-heading should be enough that people know what to expect. I also think that seeing everyday women’s bodies is important to this discussion which is why we decided to use the pictures. The Vagenda discusses these topics frequently and most of our readers are aware of that. However, we’re really sorry if you found the pictures upsetting and have now added the following info to the top of the article: (Note: this article contains images of women in their underwear alongside their BMIs)

This is really interesting, thanks for posting! I was taken to the GP when my parents worried I wasn’t eating enough aged 12, had never weighed myself before but as soon as doctors started weighing me it became an obsession. And similar with BMI, I was told to start with I was on the ‘borderline’ for anorexia but not low enough to be formally diagnosed, which just made me want to go lower. I spent over a year as an inpatient against my will but refused to recover, I’ve been out of hospital for nearly 3 years now but I still won’t let my BMI go above 15.8 which I know is really dangerous. The doctors always saw 16 as the cut off point, if you went below you were critically ill and now I’ve got a thing about it. I definitely agree with you GPs and decisions just based on BMI don’t help. Thanks again for writing this!

Thanks! I wholeheartedly agree with everything you have said about the importance of using the pictures and that the heading is pretty self-explanatory, but the updated note at the top is nonetheless welcome for those of us for whom this sort of thing is difficult to deal with. Thanks very much for publishing the article and taking my feedback into consideration

I’ve come to comment as it was suggested on Twitter that a GP’s perspective might be helpful. I’m a GP’s wife, and my speciality is public health, so hopefully I have a useful perspective. Firstly, the very valid thing you highlighted is that BMI is a population level tool. So therefore it creates a population level generalisation (I think it’s reasonable to keep using a tool even though it was developed in past centuries: lots of research shows that other measures of “fatness” are either similarly flawed – missing some and catching others incorrectly – or so totally inconvenient that they aren’t going to be used enough, e.g. Measuring body fat with clippers). It’s true that if you have lots of muscle your BMI will be higher than you’d expect, and higher than it looks. It’s true that some people have a BMI over 30 (I.e. “Obese”) when they don’t look that fat. It’s most certainly true that doctors and health professionals, and insurance companies and god knows who else get lazy and use it as a shorthand, and worse as the only definition of healthy. I agree doctors should do a better job of talking about this. There are many many ways in which the medical profession could improve its game.

But it’s not reasonable to blame all that on your GP. For one thing, the way GP practices run means they are extremely fraught and high stress environments (and I know there’s a perception they are well or even over paid: there may still be some raking it in but I can assure you that those who do are working ALL THE HOURS and the rest are in debt. I’m not asking you to be sorry for them, just to accept that perhaps right wing newspapers have an agenda). This means that a conversation about weight and exercise often feels like a “luxury”. So the conversation is short handed into BMIs. The government makes targets relating to BMI (if you are a child, or have diabetes). And almost all the research about weight and health is done using BMI.

Which brings me to my final point: like it or not, at a population level, BMI predicts poor health. And those studies will have included people who were obese and didn’t look it, people who were muscly, and those who were underweight. Just like not all smokers die of lung cancer or heart disease, not all obese people get obesity related diseases. But it is more likely. Everything in life is about playing the odds. So is this.

Bullshit measurement indicator! I’ve heard of an updated version which takes into account things like hip: waist ratios, but of course that takes more effort to measure (and I don’t know whether it would hit some of the same problems. I’m particularly not a fan of that “such as rugby players” disclaimer for some outliers, as I do a fair bit of exercise and have more muscle as a result, but I’m also not a professional athlete, so I don’t know what to make my being slightly overweight by their standards (except that I am female and therefore whatever body shape I have is never good enough for people…).

If we’re honest we all know that being very overweight or very underweight is unhealthy. A little bit either way doesn’t matter but being at the extreme end of either end of the spectrum isn’t good for you. I’m not saying that you are unhappy or a bad person if you are, it’s your body and you can choose to use it how you like…but it is more likely that you could be affected with illness associated with being overwieght or underweight.

Yes, there are exceptions to BMI and we will know if we are one of those. A muscled rugby player will come out as overweight. She could be outraged and whinge at BMI, or she could look in the mirror and think…look at my muscles. I can play sport for 80 mins and I love how powerful my body is. I’ve actually never met an athlete who gets upset that they would be classed at overweight by the BMI scale. But I have met non sport players say the same thing and sadly it’s just not true, they are overweight and have trouble getting up the stairs.

BMI is not very good if you are a long distance runner (Saying that a lot of endurance athletes have issues with under eating), but you know that your body shape works for what sport you do. But, very underweight people who couldn’t complete a lap of their house? Not healthy. Doesn’t mean you are unhappy or a bad person, but not healthy in the medical way.

However, for people that may just want to know if they are roughly in the ball park for weight for their height, BMI is just a very simple maths formula that is trying to make it easier for people to understand their weight.

If you think it is substandard, educate yourself about better tools- available for free on the Internet. They are more accurate, but they take more time, need more info and are more likely to be used incorrectly. So the NHS has tried to use the simple and broadly effective method- that’s not an attack against women.

I’m Australian, not English, but I’ve had similar problems with GPs. I was having severe chest pains and saw the same doctor at my university clinic several times to try and work out the cause, the doctor had done a fairly thorough examination of me and had done some fairly extensive blood tests. None of that showed any problems, and during the last visit I had with her, where she basically shrugged and told me she had no idea, she literally stopped talking mid-sentence, looked me up and down, and asked me how much I weighed. She put me on the scale, measured my height, and used BMI to determine I was about fifteen kilograms overweight. When I told her I was comfortable with my weight, she told me I would feel much better about myself if I lost weight and referred me to a dietician. All without asking me about my diet or lifestyle. And with nothing in her previous examination of me showing I had any medical need to lose weight. I already struggled with disordered eating and had a difficult relationship with my body and spent the bus ride home on the verge of tears. I ended up going to a physiotherapist, who determined that the weight of uni books and equipment I had been carrying around had been damaging my spine and causing my ribs to pull, ending in the chest pain.

I’m one of those individuals. I workout 6 days a week (weightlifting, yoga, and HIIT cardio) have an entirely organic and clean diet, have abs, muscular legs, and I can lift 1 1/2x my body weight.

Yet my BMI (26) indicates that I’m overweight. I get your point, that most of the time it’s a decent indicator of overall health… What I don’t get is why our society is so supportive and reliant on BMI’s that EVERY single GP has told me I’m overweight, need to workout more, and eat less.

It only takes a single glance and a 10 second conversation to realise that isn’t the case, but no- no matter how much I protest ‘I’m the one who’s flawed’. You know what this results in? Me going home with my confidence shattered and wondering how the hell I could fit within society’s standards.

BMI is never, ever going to be accurate for women. It was based on only 100 men, no women. It is well known that women naturally have a higher amount of body fat and should as such weigh more than men height for height – and yet they insist on using this same scale for both sexes.

I loved this article – BMIs have been making me angry for a few years now , and I’m so happy to see it’s not just me. I have no idea what they should be replaced with, but someone needs to tell people BMIs aren’t actually a legitimate and accurate way of determining your health, or your attractiveness, for that matter. I have been slim my entire life, though in perfect health and very energetic, with a huge appetite and thankfully (probably because I’m on the “acceptable” side of the scale, deplorable as that may be) with no big body issues. Yet I was flagged as “dangerously underweight” when I did a BMI test for medical insurance purposes, and advised to seek medical help immediately (my BMI is 16.7). I applied to participate in egg donation and was refused solely because of my unacceptable BMI, though I have a perfect bill of health. Over the years I have come to fear that I am infertile, have a malfunctioning thyroid, that I might be subconsciously undereating – basically that I am unattractive and unhealthy. Many of my close friends, who wear perhaps 2 to 3 clothes sizes larger than I do, have been told by the very same all-knowing BMI that they are overweight. Normal, happy, active, healthy people. It seems to me you need to fall within a very narrow bracket to be of acceptable weight. according to the BMI, and it frightens me that we are still basing much of our opinion of ourselves, let alone our decisions, on this outdated and inaccurate scale.